I hereby consent to avail the Health Shield 360 policy (UIN ICIHLGP22083V022122) underwritten by ICICI Lombard General Insurance

Company Limited ("ICICI Lombard"). I confirm that the information furnished by me in my operative account and this enrollment form
together shall constitute the proposal documents for the Health Shield 360 policy.

Master Policy No 4 1 7 7 i / M S T R / 2 4 5 5 8 0 7 7 9 / 0 0 / 0 0 0
GUIDELINES FOR COMPLETION OF THE FORM (To be filled by applicant)
I nsurance is a contract of Utmost Good Faith requiring the I nsured not only to disclose all material facts but also not to suppress any material facts in response to
the questions in the enrolment form. Please disclose all material facts while filing in the enrolment form.
The Policy shall become void at the option of Insurer, in the event of any untrue or incorrect statement, misrepresentation, non-description or non-disclosure in any
material par cular in the enrolment form/personal statement, declara on and connected documents or any material informa on having been withheld by the
Applicant or any one acting on his behalf.
Terms and Conditions
Initial waiting period of 30 days for all illnesses (except Hospitalisation due to injury or accident).
The liability of the insurer does not commence until this enrollment form has been accepted by the insurer and premium realised.
Declared & accepted Pre-existing diseases will be covered after initial waiting period.
Specified disease/procedure waiting period of 12 months is applicable.
Expense related to hypertension, diabetes and cardiac conditions will not be covered within 90 days from the policy commencement date unless they are PED.
Premium at the time of renewal is subject to change in case of addition or deletion of the insured member and/ or basis change in age band of eldest insured
member.
The Insured person may have to undergo pre policy medical checkup at our designated network provider/ service provider depending upon his/her age and SI
opted. The insurer will bear 100% of the expenses incurred on the acceptance of the proposal. In case the proposal is not accepted, the premium shall be
refunded post deduction of the expenses incurred for the medical tests.
Pre-acceptance Tele screening is mandatory above age of 55 years and also in case customer has declare any Pre-existing disease. Pre-policy Medical Checkup
is mandatory above age of 65 years and also for Sum Insured above 50 Lakhs.
Deductible opted will applicable on aggregate basis for all hospitalisation expenses during the policy year

APPLICANT / CUSTOMER INFORMATION Please fill all the particulars in CAPITAL letters only

Applicant Name (please leave a space after each part of name)

Mr. / Ms. / Dr.: D O B B A L A S U R Y A M

Date of Birth: 2 1 0 4 1 9 9 4 Gender:Male Female Transgender Mobile Number*: 9 3 4 7 4 6 9 8 7 3

E-mail Address: d . s u r y a m 1 9 9 3 @ g m a i l . c o m

PAN Number: - - - - - - - - - - Virtual ID: - - - - - - - - - - -

NOMINEE/ APPOINTEE DETAILS

Name of D S h i v a R a j Date of Birth: 1 3 1 2 1 9 9 5

Nominee:

Relationship: B r o t h e r

DETAILS OF PERSONS TO BE INSURED

Insured Full Name (First, Middle, Last) Gender Date of Birth Relationship PED
No. (M/F/T) (DD/MM/YY) with Applicant

1. DOBBALA SURYAM M Self Diabetes Mellitus Sugar

2 1 / 0 4 / 1 9 9 4 History
2. / /
3. / /
4. / /

DETAILS OF THE INSURANCE COVER

Sum Insured Plan Type Deductible Premium

 1 5 0 0 0 0 0 I N D I V I D U A L 2 0 0 0 0 0 4 6 4 9

STATUTORY WARNING

PROHIBITION OF REBATES
(Under Section 41 of Insurance Act 1938)
1. No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any
kind of risk relating to lives or property, in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor
shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published
prospectuses or tables of the Insurer.
2. Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to Ten lakh rupees.

DECLARATION
I hereby give my consent to the company to contact me for health and related services.
I hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or par culars given by me are true and
complete in all respects to the best of my knowledge and that I am authorized to propose on behalf of these other persons.
I understand that the informa on provided by me will form the basis of the insurance policy, is subject to the board approved underwri ng policy of the insurance
company and that the policy will come into force only after full receipt of the premium chargeable.
I further declare that I will no fy in wri ng any change occurring in my occupa on or general health a er the proposal has been submi ed but before
communication of the risk acceptance by the insurer.
I declare and consent to the insurer seeking medical informa on from any doctor or from a hospital who has a ended to my health or from any past or present
employer concerning anything which affects my physical or mental health and seeking informa on from any insurance company to which an applica on for
insurance has been made by me for the purpose of underwriting the proposal and/ or claim settlement.
I authorise the insurer to share informa on pertaining to my proposal including the medical records for the sole purpose of proposal underwri ng and/or claims
settlement and with any Government and /or Regulatory authority.
I hereby give my consent to enroll me into Health Shield 360 I nsurance Policy underwri en by I CI CI Lombard General I nsurance Co. Ltd. (I RDA Reg No 115)agree
I to
abide by the Terms & Condi ons of the policy and provide my consent to share my personal details, as required, regarding my enrollment into the policy with the
insurer.

Place: Mumbai Date: 1 3 / 0 5 / 2 0 2 4

Registered Address: ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple,
Prabhadevi, Mumbai 400 025.
Visit us at www.icicilombard.com. Mail us at customersupport@icicilombard.com
Toll Free Number 1800 2666. SMS Facility "HEALTHCLAIM" to 575758. IRDA Reg. No. 115. CIN: U67200MH2000PLC129408. UIN: ICIHLGP22083V022122.